Paraparesis associated with ruptured anterior cerebral artery territory aneurysms

BACKGROUND: Paraparesis is a rare but characteristic manifestation of ruptured anterior communicating artery or anterior cerebral artery (ACA) aneurysms, but the pathogenesis remains unclear. This study investigated the neuroimaging and clinical features of patients with such paraparesis to evaluate possible causes. METHODS: Nine of 178 patients with ruptured anterior communicating artery or ACA aneurysms presented with paraparesis among 462 patients with subarachnoid hemorrhage (SAH) admitted between May 1996 and November 2001. Diffusion-weighted magnetic resonance (MR) imaging was performed within 48 hours of the onset of SAH in 4 of these 9 patients. The clinical course and neuroimaging studies of these 4 patients were retrospectively reviewed. RESULTS: Diffusion-weighted MR imaging revealed -intensity areas in the medial aspects of the bilateral frontal lobes, which were supplied by the ACAs and distal to the aneurysms, in all 4 patients. These high-intensity lesions had normal to subnormal values of apparent diffusion coefficient (ADC). Most of the high-intensity lesions recovered and did not result in the final lesions regardless of the ADC values, but some lesions with subnormal ADC values resulted in cerebral infarction. Paraparesis was transient and almost completely resolved in 3 patients. CONCLUSIONS: Diffusion-weighted MR imaging detected primary brain damage in the ACA territories caused by acute SAH, which was compatible with the clinical paraparesis. Primary brain damage caused by SAH may include 3 types of lesions: reversible with normal ADC value, reversible with subnormal ADC value, and irreversible with subnormal ADC value.     

Transjugular intrahepatic portosystemic shunt in a patient with cavernomatous portal vein occlusion

A 23-year-old woman with liver cirrhosis secondary to primary sclerosing cholangitis was referred to us for the treatment of recurrent bleeding from esophageal varices that had been refractory to endoscopic sclerotherapy. Her portal vein was occluded, associated with cavernous transformation. A transjugular intrahepatic portosystemic shunt (TIPS) was performed after a preprocedural three-dimensional computed tomographic angiography evaluation to determine feasibility. The portal vein system was recanalized and portal blood flow increased markedly after TIPS. Esophageal varices disappeared 3 weeks after TIPS. Re-bleeding and hepatic encephalopathy were absent for 3 years after the procedure. We conclude that with adequate preprocedural evaluation, TIPS can be performed safely even in patients with portal vein occlusion associated with cavernous transformation.     

Postoperative management using intensive patient-controlled epidural analgesia and early rehabilitation after an esophagectomy

Purpose  Patient-controlled epidural analgesia (PCEA) was developed for use after surgery for thoracic esophageal cancer to relieve wound pain, introduce early rehabilitation, and provide an uneventful postoperative recovery. Methods  This retrospective study investigated 22 patients who underwent esophageal surgery to determine the efficacy of postoperative management with PCEA. In the PCEA group (n = 12), patients had two epidural catheters inserted to cover both the thoracic and abdominal incision with a patient-controlled bolus capability. Results  Postoperative mechanical ventilation was administered in all cases in the control group (n = 10). On the other hand, this was only necessary in two patients in the PCEA group. The amount of time the patients stayed in the intensive care unit and the hospital was significantly shorter in the PCEA group than in the control group (P < 0.001 and P < 0.01, respectively). Respiratory complications occurred in four patients in the control group, and none in the PCEA group. The mean number of supplemental analgesics administered for breakthrough pain until the 7th postoperative day was 5.5 in the control group, and 1.3 in the PCEA group (P < 0.001). Conclusions  Early rehabilitation is facilitated with intensive PCEA, while it also improves postoperative management and reduces hospitalization after esophageal surgery.     

High incidence of microbleeds in hemodialysis patients detected by T2*-weighted gradient-echo magnetic resonance imaging

The incidence and characteristics of microbleeds in hemodialysis (HD) patients were investigated to elucidate the clinical significance with T(2)(*)-weighted gradient-echo magnetic resonance (MR) imaging. The 57 patients with chronic renal failure maintained by HD had no previous history of stroke. The control group consisted of 53 patients without previous history of stroke or chronic renal failure. The incidence and the number of microbleeds were assessed in the HD and control groups. The findings of microbleeds with T(2)(*)-weighted gradient-echo MR imaging were compared with those of T(1)- and T(2)-weighted MR imaging in HD patients. The incidence of microbleeds was significantly greater in the HD patients compared with the control patients. T(2)(*)-weighted gradient-echo imaging revealed a total of 44 microbleeds in 11 HD patients. T(2)-weighted imaging demonstrated 13 of 44 microbleeds as hyperintensity, whereas T(1)-weighted imaging demonstrated 12 lesions as hypointensity. T(2)- and T(1)-weighted imagings did not demonstrate any findings in 31 and 32 lesions, respectively. T(2)(*)-weighted gradient-echo MR imaging is effective to detect microbleeds which may be a predictor of intracerebral hemorrhage in HD patients and should be included in the protocol for the study of cerebrovascular disease, because T(2)- and T(1)-weighted MR imaging recognizes microbleeds as lacunar infarction.     

Prevalence of Synchronous Colorectal Neoplasms Detected by Colonoscopy in Patients with Gastric Cancer

Purpose Our purpose was to study the characteristics of colorectal neoplasms in patients with gastric cancer (GC). Methods The study group comprised GC patients who underwent colonoscopy before resection of their GC. We examined the prevalence, site, and histology of colorectal neoplasms, as well as the clinicopathological features and treatment of the patients who had synchronous colorectal cancers (CRC). The logistic regression model was applied to investigate the features of the GC patients with concurrent CRC. Results We studied 466 GC patients (mean age 64.5 years; 147 women, 319 men), 143 (31%) of whom had a family history of gastrointestinal cancer. Synchronous colorectal adenoma and cancer were detected in 182 (39%) and 18 (4%) patients, respectively. Among the 18 synchronous CRCs, 11 were in the early stages and 10 of these were resected endoscopically. The other eight required simultaneous open radical surgery. All the GC patients with synchronous CRC were older than 50 years. Statistical analysis did not show a significant difference between the features of the patients with and those without concurrent CRC. Conclusions The possibility of synchronous colorectal neoplasms in GC patients cannot be disregarded in clinical practice; however, screening of the large bowel may not be necessary in GC patients younger than 50 years.     

Treatment of lower limb deformities and limb-length discrepancies with the external fixator in Ollier's disease

Background In this study, we addressed two questions on the treatment for Ollier's disease: (1) how much callus formation occurs when an osteotomy is performed intralesionally and (2) how is the stability of the wires and half-pins that are inserted intralesionally. Methods Four children with Ollier's disease underwent treatment of 12 lower limb segments using distraction osteogenesis until completion of their growth. All osteotomies were performed at the centers of the deformities, resulting in a total of seven osteotomies performed intralesionally. Results Full correction of the deformity and full restoration of length were achieved in all cases, but a residual limb-length discrepancy of <10 mm remained. The mean external fixation index in the intralesional distraction osteogenesis group was 39.7 days/cm versus 30.8 days/cm in the extralesional distraction osteogenesis group. Conversion from abnormal cartilage to normal regenerate bone was seen in only one segment. Although approximately two-thirds of the wires and half-pins were inserted intralesionally, in all but one case (in which an iatrogenic fracture occurred) the wires and half-pins were well stabilized throughout the external fixation period. Conclusions Although deformity and limb-length discrepancies due to Ollier's disease were successfully resolved by distraction osteogenesis, enchondroma may arise in distracted calluses when osteotomized intralesionally. However, the stability of the external fixator was sufficient to lengthen limbs and correct deformities even when wires and half-pins were inserted intralesionally.     

Multiphase ECG-triggered 3D contrast-enhanced MR angiography: utility for evaluation of hilar and mediastinal invasion of bronchogenic carcinoma

The purpose of this study was to evaluate the usefulness of cardiac synchronized magnetic resonance angiography [electrocardiographically (ECG)-triggered MRA] for improving image quality and detection of hilar and mediastinal invasion of bronchogenic carcinoma. Fifty patients, suspected of having hilar or mediastinal invasion of bronchogenic carcinoma, underwent contrast-enhanced computed tomography and MR imaging including conventional and ECG-triggered MRA. Twenty patients subsequently also underwent surgical resection. Vascular enhancement-to-background ratio (VBR), vascular enhancement-to-tumor ratio (VTR), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and image quality scores of thoracic vessels obtained with both MRA techniques were determined and compared. In addition, the diagnostic accuracy of tumor invasion of pulmonary vessels was compared. VBRs and VTRs of both MRA techniques were not significantly different. ECG-triggered MRA significantly improved SNRs and CNRs (P < 0.05). Two readers judged that overall image quality of ECG-triggered MRA was better than that of conventional MRA (kappa > or = 0.41). In conclusion, ECG-triggered MRA improves the image quality and the detection of hilar and mediastinal invasion of bronchogenic carcinoma.     

Effect of Prostaglandin E1 on Ischemia–Reperfusion Injury During Abdominal Aortic Aneurysm Surgery

Objective Abdominal aortic aneurysm (AAA) surgery subjects the lower extremities to ischemia and reperfusion. Although it is not extensive or prolonged, ischemia of the lower extremities during aortic cross-clamping is gradually and steadily induced. We studied the effects of prostaglandin E₁ (PGE₁) on ischemia–reperfusion injury of the lower extremities during AAA repair. Methods During AAA surgery, two near-infrared spectroscopy probes were positioned on each calf muscle to monitor oxygen metabolism in the lower extremities. We also measured lactate concentration in both iliac veins. Results Near-infrared spectroscopy signals responded sensitively to aortic cross-clamping and declamping. Lactate increased time-dependently during aortic cross-clamping. The continuous venous administration of PGE₁ (20 ng/kg per minute) inhibited the accumulation of lactate during aortic cross-clamping. Declamping of the first iliac artery resulted in a further but transient increase in ipsilateral venous lactate, which may be one component in the mechanism of declamping shock. Prostaglandin E₁ eliminated the transient increase in ipsilateral lactate. The administration of PGE₁ inhibited the contralateral accumulation of lactate after first declamping, and the lactate level decreased gradually before the second declamping. Conclusions Prostaglandin E₁ seems to have a protective effect against ischemia–reperfusion injury of the lower extremities during AAA surgery.